scholarly journals Health workers’ psychological distress during early phase of the covid-19 pandemic in Morocco

2021 ◽  
Author(s):  
Jihane Belayachi ◽  
Sarah Benammi ◽  
Hasnae Chippo ◽  
Rhita Nechba Bennis ◽  
Naoufel Madani ◽  
...  
Keyword(s):  
Health Worker ◽  
Early Phase ◽  
Health Workers ◽  
Early Period ◽  
University Hospital ◽  
Anxiety And Depression ◽  
Cross Sectional ◽  
Protective Measures ◽  
Protection Measures ◽  
Psychological Burden

ABSTRACTIntroductionThe mental being of healthcare workers with the COVID 19 pandemic is a determinant of their resilience. We investigated the psychological impact of health workers during early phase of Covid 19 pandemic in Morocco.MethodsThis was a cross-sectional study based on a survey of health workers of the Rabat University Hospital Ibn-Sina in Morocco. Data were collected during the first week of health emergency state –between 23 and 30 march-related to the covid-19 pandemic declaration in Morocco. Sociodemographic, health characteristics and professional characteristics of each health worker were collected. We also evaluated the knowledge of health workers concerning the protective measures against COVID 19. The mental health status of the health workers was investigated using the Arabic validated version of HADS 14 items, evaluating hospital anxiety and depressionResultsTwo hundred eighty-seven health workers were included.The mean age was 34.4±12.18 year; and 64.5% were female, 54% have been trained regarding protection procedures, and 94.8% declared that they are aware of individual protection measures. The incidence of anxiety and depression was respectively 77.4% and 73.9%. High degree of anxiety and depression was associated with female gender. However, Higher degree of anxiety was also related to function, specialty of practice, and knowledge of the protective measures against COVID-19.ConclusionWe reported the result of the first evaluation of psychological burden of health worker during early period of COVID-19 pandemic in a developing country. The study showed high frequency of anxiety and depression among Moroccan health worker in a hospital faced to COVID-19 patient management.

Psychological distress in patients undergoing urological surgery: A cross-sectional study

2021 ◽  
pp. 205141582110140
Author(s):  
Nuala Murray ◽  
Charles O’Connor ◽  
Rhona Dempsey ◽  
Sean Liew ◽  
Helen Richards ◽  
...  
Keyword(s):  
Psychological Distress ◽  
Repeated Measures ◽  
Depression Scale ◽  
University Hospital ◽  
Anxiety And Depression ◽  
Hospital Anxiety ◽  
Level Of Evidence ◽  
Cross Sectional ◽  
Post Surgery ◽  
Oncological Patients

Purpose: The purpose of this study was to evaluate the psychological distress of urological and uro-oncological patients undergoing surgery. Methods: Patients who presented to Mercy University Hospital from October 2019–May 2020 were consecutively recruited. Demographic and clinical characteristics including age, gender, marital status, type of surgery (uro-oncology or general urology), endoscopy or open surgery were gathered. Mood was evaluated using the Hospital Anxiety and Depression Scale prior to admission, prior to discharge and 6 weeks post-surgery. Results: A total of 118 participants (79.7% male) completed the Hospital Anxiety and Depression Scale prior to admission, prior to discharge and at 6 weeks post-surgery. Forty patients (33.9%) underwent uro-oncology-related surgery. At pre-admission 39 patients (33%) fell into a possible-probable clinical category for anxiety and 15 (12.7%) for depression. Older patients had significantly lower anxiety levels than younger patients ( p⩽0.01). There were no differences between patients undergoing uro-oncology or more general urology surgery and levels of anxiety or depression. Repeated measures analysis of variance with age as a covariate indicated no significant differences in Hospital Anxiety and Depression Scale anxiety scores over time. There was a statistically significant reduction in Hospital Anxiety and Depression Scale depression scores over the three assessment time points ( p=0.004). Conclusion: Over one-third of patients were experiencing moderate to severe levels of psychological distress pre-surgery – higher than levels previously reported in uro-oncological patients. Surprisingly, there was no difference in anxiety and depression scores in uro-oncology and urology patients. Psychological distress in both uro-oncology and more general urology patients should be considered in the surgical setting. Level of evidence Moderate

scholarly journals Prevalence and factors associated with minor psychiatric disorders in hospital housekeeping workers*

2017 ◽  
Vol 51 (0) ◽  
Author(s):  
Cintia da Silva Marconato ◽  
Ana Carolina de Souza Magnago ◽  
Tânia Solange Bosi de Souza Magnago ◽  
Graziele de Lima Dalmolin ◽  
Rafaela Andolhe ◽  
...  
Keyword(s):  
Psychiatric Disorders ◽  
Health Workers ◽  
Leisure Activities ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Cross Sectional ◽  
Factors Associated ◽  
Study Population ◽  
Self Reporting Questionnaire ◽  
Minor Psychiatric Disorders

Abstract OBJECTIVE Investigating the prevalence and factors associated with minor psychiatric disorders (MPDs) in Hospital housekeeping workers. METHOD A cross-sectional study carried out in 2013 with workers from the cleaning service of a public university hospital in Rio Grande do Sul, Brazil. Data were collected through a form containing sociodemographic, occupational, habits and health variables. The Self-Reporting Questionnaire-20 was used in order to evaluate MPDs. RESULTS The study population consisted of 161 workers. The overall prevalence of suspected MPD was 29.3%. The chances of suspected MPDs were higher in workers with Effort-Reward Imbalance, those who did not have time or who occasionally had time for leisure activities, and those taking medications. CONCLUSION The prevalence of MPDs was similar to that found in the literature for health workers. Therefore, we consider it important to include these workers in institutional programs for continuing health education.

scholarly journals Corona virus fear among health workers during the early phase of pandemic response in Nepal: a web-based cross-sectional study

2020 ◽  
Author(s):  
Pratik Khanal ◽  
Navin Devkota ◽  
Minakshi Dahal ◽  
Kiran Paudel ◽  
Shiva Raj Mishra ◽  
...  
Keyword(s):  
At Risk ◽  
Family Member ◽  
Chronic Diseases ◽  
Early Phase ◽  
Health Workers ◽  
Cross Sectional Study ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Web Based ◽  
Factors Associated

AbstractBackgroundHealth workers involved in COVID-19 response might be at risk of developing fear and psychological distress. This study aimed to identify factors associated with COVID-19 fear among health workers in Nepal during the early phase of pandemic.MethodsA web-based cross-sectional survey was conducted in the month of April-May 2020 among 475 health workers directly involved in COVID-19 management. The Fear Scale of COVID 19 (FCV-19S) was used to measure the status of fear. Scatter plots were used to observe the relationship between fear and other psychological outcomes: anxiety, depression and insomnia. Multivariable logistic regression was done to identify factors associated with COVID fear.ResultsCOVID-19 fear score was moderately correlated with anxiety and depression, and weakly correlated with insomnia (p<0.001). Nurses (AOR=2.29; 95% CI: 1.23-4.26), health workers experiencing stigma (AOR=1.83; 95% CI: 1.12-2.73), those working in affected district(AOR=1.76; 95% CI: 1.12-2.77) and presence of family member with chronic diseases (AOR=1.50; 95% CI: 1.01-2.25) was associated with higher odds of developing COVID-19 fear as compared to other health workers, health workers not experiencing stigma, working in non-affected district and not having family member with chronic diseases respectively.ConclusionNurses, health workers facing stigma, those working in affect district and having family member with chronic diseases were more at risk of developing COVID-19 fear. It is thus recommended to improve work environment to reduce fear among health workers, employ stigma reduction interventions, and ensure personal and family support for those having family member with chronic diseases.

scholarly journals Mental health of nursing in coping with COVID-19 at a regional university hospital

2020 ◽  
Vol 73 (suppl 2) ◽  
Author(s):  
Eduardo Bassani Dal’Bosco ◽  
Lara Simone Messias Floriano ◽  
Suellen Vienscoski Skupien ◽  
Guilherme Arcaro ◽  
Alessandra Rodrigues Martins ◽  
...  
Keyword(s):  
Mental Health ◽  
Depression Scale ◽  
University Hospital ◽  
Anxiety And Depression ◽  
Graduate Degree ◽  
Public Servants ◽  
Cross Sectional ◽  
Mental Health Nursing ◽  
Nursing Professionals ◽  
The Impact

ABSTRACT Objective: to identify prevalence and factors associated with anxiety and depression in nursing professionals who work to cope with COVID-19 at a university hospital. Methods: a cross-sectional observational study using a sociodemographic questionnaire and Hospital Anxiety and Depression Scale, with 88 nursing professionals. Data were analyzed using absolute and relative frequency and Statistical Package for the Social Sciences. Results: there was prevalence of anxiety (48.9%) and depression (25%). The majority of the sample consisted of women over 40 years old, married or in a common-law marriage, white, with higher education or graduate degree, with an income above 3,000.00 reais, public servants, working 40 hours a week and working in the hospital from 1 to 5 years. Conclusion: we must consider the impact on mental health nursing caused by COVID-19 and intervene with coping strategies to minimize the suffering of professionals.

scholarly journals The psychological burden in survivors of stroke and caregivers dyads in Kinshasa (Democratic Republic of Congo): a cross-sectional study

2021 ◽  
Author(s):  
Germain Manzekele Bin Kitoko ◽  
Bives Mutume. Vivalya ◽  
Martial Mumbere Vagheni ◽  
Thierry Matonda Ma Nzuzi ◽  
Sam Mampunza Lusambulu ◽  
...  
Keyword(s):  
Democratic Republic Of Congo ◽  
Healthcare Providers ◽  
Depression Scale ◽  
Cross Sectional Study ◽  
Anxiety And Depression ◽  
Stroke Survivors ◽  
Sectional Study ◽  
Cross Sectional ◽  
Psychological Burden ◽  
Zarit Burden Inventory

Abstract Background: Stroke exposes the patients and the caregivers to the development of burden in terms of health, economic and social costs. Few studies have focused on the relationship between the psychological burden and the level of disability in stroke survivors and caregiver dyads. Methods: This cross-sectional study aimed at determining the psychological burden of stroke in patients and caregivers in Kinshasa. 85 stroke survivors and caregivers dyads were screened using the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, and the Rankin’s modified Scale to determine respectively the depression, the anxiety in stroke survivors as well as the caregivers’ psychological burden. Results: Up to fifty percent of survivors of stroke had a severe disability, associated with a high risk of the occurrence of the psychological burden. Nearly eighty-five percent of caregivers showed a moderate psychological burden. The stroke survivors developed more depression than anxiety. Caregivers developed more likely anxiety and depression than stroke survivors. Conclusions: There is a positive relationship between the psychological burden in caregivers and the level of disability in stroke survivors far from the acute phase of the stroke. Healthcare providers working with the survivors of stroke should assess for anxiety and depression in caregivers.

scholarly journals A Cross-Sectional Survey of the Workplace Factors Contributing to Symptoms of Anxiety and Depression Among Nurses and Physicians During the First Wave of COVID-19 Pandemic in Two US Healthcare Systems

2021 ◽  
Author(s):  
Igor Burstyn ◽  
Karyn Holt
Keyword(s):  
Depression Scale ◽  
Participation Rate ◽  
Healthcare Systems ◽  
Working Environment ◽  
Mitigation Measures ◽  
Anxiety And Depression ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Psychological Burden ◽  
Nurses And Physicians

Abstract Background Anxiety and depression among physicians and nurses during the COVID-19 pandemic in the USA are not well described and their modifiable causes are poorly understood. Methods We conducted a cross-sectional survey of symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) among physicians and nurses in two US healthcare systems in June through September 2020; participation rate was 5–10%. We described features of work as well as their perceptions and associated concerns in relation to the risk of anxiety and depression, while controlling for health history via regression and path analyses. Results About a third of 684 nurses and 185 physicians surveyed showed symptoms of anxiety or depression, and the excess of symptoms of mood disorders was particularly prominent in nurses. The belief that one was infected was a dominant correlate of both anxiety and depression. This belief was more associated with history of symptoms of pneumonia than the contact with COVID-19 diagnosed patients. Factors found to be associated with reduced anxiety and depression in this working environment were having confidence in the competent use of and access to personal protective equipment, maintaining usual working hours, being surrounded by colleagues who were both sufficient in numbers and not stressed, and the support of immediate family and religious communities. Involvement in aerosol-generating procedures with infected patients was linked with lower depression in nurses but higher among physicians. Likewise, the setting of recent patient encounters affected risk of anxiety and depression differently for physicians and nurses. Conclusions Our findings may help develop mitigation measures and underscore the need to help nurses and physicians bear the psychological burden of the COVID-19 pandemic and similar events in the future.

scholarly journals Antiretroviral Adverse Drug Reactions Pharmacovigilance in Harare City, Zimbabwe, 2017

2018 ◽  
Author(s):  
Hamufare Mugauri ◽  
Owen Mugurungi ◽  
Tsitsi Juru ◽  
Notion Gombe ◽  
Gerald Shambira ◽  
...  
Keyword(s):  
Health Worker ◽  
Adverse Drug Reactions ◽  
Health Workers ◽  
Likert Scale ◽  
Pharmacovigilance System ◽  
Drug Reactions ◽  
Cross Sectional ◽  
Therapeutic Decisions ◽  
Clinical Records ◽  
Harare City

AbstractIntroductionKey to pharmacovigilance is spontaneously reporting all Adverse Drug Reactions (ADR) during post-market surveillance. This facilitates identification and evaluation of previously unreported ADR’s, acknowledging the trade-off between benefits and potential harm of medications. Only 41% ADR’s documented in Harare city clinical records for January to December 2016 were reported to Medicines Control Authority of Zimbabwe (MCAZ). We investigated reasons contributing to underreporting of ADR’s in Harare city.MethodsA descriptive cross-sectional study and the updated Centers for Disease Control (CDC) guided surveillance evaluation was conducted. Two hospitals were purposively included. Seventeen health facilities and 52 health workers were randomly selected. Interviewer-administered questionnaires, key informant interviews and WHO pharmacovigilance checklists were used to collect data. Likert scales were applied to draw inferences and Epi info 7 used to generate frequencies and proportions.ResultsOf the 52 participants, 32 (61.5%) distinguished the ADR defining criteria. Twenty-nine (55.8%) knew system’s purpose whilst 28 (53.8%) knew the reporting process. Knowledge scored average on the 5-point-Likert scale. Thirty-eight (73.1%) participants identified ADR’s following client complaints and nine (1.3%) enquired clients’ medication response. Forty-six (88.5%) cited non-feedback from MCAZ for underreporting. Inadequate ADR identification skills were cited by 21 (40.4%) participants. Reporting forms were available in five (26.3%) facilities and reports were generated from hospitals only. Forty-two (90.6%) clinicians made therapeutic decisions from ADR’s. Averaged usefulness score was 4, on the 5-point-Likert scale. All 642 generated signals were committed to Vigiflow by MCAZ, reflecting a case detection rate of 4/ 100 000. Data quality was 0.75–1.0 (WHO) and all reports were causally assessed.ConclusionThe pharmacovigilance system was useful, simple, and acceptable despite being unstable, not representative and not sensitive. It was threatened by suboptimal health worker knowledge, weak detection strategies and referral policy preventing ADR identification by person place and time. Revisiting local policy, advocacy, communication and health worker orientation might improve pharmacovigilance performance in Harare city.

scholarly journals Tingkat Kecemasan pada Andikpas Usia 14-18 Tahun Menjelang Bebas di Lembaga Pembinaan Khusus Anak Kelas II

2018 ◽  
Vol 1 (1) ◽  
pp. 78
Author(s):  
Maya Atikasuri ◽  
Henny Suzana Mediani ◽  
Nita Fitria
Keyword(s):  
Health Workers ◽  
Sampling Technique ◽  
Anxiety Scale ◽  
Transitional Period ◽  
Cross Sectional ◽  
Psychological Burden ◽  
Psychological States ◽  
Consecutive Sampling ◽  
Self Rating ◽  
Quantitative Descriptive

Masalah kenakalan remaja telah menjadi salah satu masalah pokok yang dihadapi oleh Indonesia. Kejadian dan kualitas kenakalannya terus meningkat hingga menjurus pada tindak kriminalitas yang menyebabkan remaja terjerat di ranah hukum. Stigma negatif di masyarakat yang diberikan kepada mantan tahanan membuat Andikpas enggan keluar dari LPKA dan cenderung merasakan kecemasan menjelang masa kebebasannya, terlebih lagi usia remaja merupakan usia dimana keadaan emosional dan psikologis yang belum stabil membuat remaja mudah mengalami kecemasan dan berdampak tidak baik jika terus dibiarkan. Tujuan dari penelitian ini adalah untuk mengetahui gambaran tingkat kecemasan pada Andikpas menjelang bebas di LPKA Kelas II Bandung.Metode penelitian yang digunakan adalah deskriptif-kuantitatif dan teknik consecutive sampling dengan populasi Andikpas menjelang bebas sebanyak 56 orang. Instrumen yang digunakan adalah Zung’s Self-Rating Anxiety Scale (ZSAS) dengan skala likert.Hasil penelitian menunjukkan bahwa dari 56 Andikpas yang diteliti hampir setengahnya yaitu 25 Andikpas (44,64%) tidak mengalami kecemasan, sementara sebagian besar Andikpas yang mengalami kecemasan yaitu 19 Andikpas (33,93%) mengalami kecemasan ringan-sedang, dan sebagian kecil yaitu sebanyak 9 Andikpas (16,07%) mengalami kecemasan berat, serta yang paling sedikit yaitu sebanyak 3 Andikpas (5,35%) mengalami panik.Simpulan dari penelitian ini adalah bahwa hampir setengahnya dari Andikpas yang diteliti tidak mengalami kecemasan, namun lebih dari setengahnya juga Andikpas pada penelitian ini mengalami kecemasan baik dari tingkatan ringan sampai dengan panik. Peningkatan program pembinaan dan konseling serta pemberdayaan tenaga kesehatan di LPKA sangat dibutuhkan agar dapat menurunkan tingkat kecemasan pada Andikpas.Kata kunci : Andikpas, kenakalan remaja, menjelang bebas, tahanan. Description of Anxiety Disorder among Inmate 14–18 Years Old Pre Release at Lembaga Pembinaan Khusus Anak Class IIAbstractJuvenile delinquency has become one of the main problems in Indonesia. The incidence and mischievousness quality increase which is lead to crime action. This situation may cause adolescent entangled in the realm of law. The negative stigma in society given to inmates former make inmate reluctant to get out of LPKA and tends to feel anxiety ahead of their pre-release. Adolescent is a phase of a transitional period from children into adulthood where emotional and psychological states are not stable, and anxiety is need to be noticed. Moreover, psychological burden that experienced by adolescent was harder when they lived in LPKA. This study aims to identify anxiety scale of pre-release juvenile inmates at LPKA Class II Bandung.This study use quantitative descriptive research with cross-sectional approach and consecutive sampling technique with 56 pre-release juvenile inmates as population and used Zung’s Self-Rating Anxiety Scale (ZSAS) with Likert Scale as data analyze. The result showed that 25 Andikpas (44.64%) did not experience anxiety, then most of them experienced anxiety with the explenation: 19 Andikpas (33,93%) experience mild-moderate anxiety, 9 Andikpas (16.07%) experiencing severe anxiety, and 3 Andikpas (5.35%) experiencing panic.The conclusion of this study is the level of anxiety experienced by Andikpas is nearly half of Andikpas did not experience anxiety, but more than half of Andikpas in this study experienced anxiety either from mild to panic levels. Improvement of coaching and counseling programs and the empowerment of health workers in LPKA is needed to reduce the level of anxiety in Andikpas.Keyword: Andikpas, inmates, juvenile delinquency, pre-release.

scholarly journals Attitudes and Intentions toward COVID-19 Vaccination among Spanish Adults: A Descriptive Cross-Sectional Study

Vaccines ◽  
2021 ◽  
Vol 9 (10) ◽  
pp. 1135
Author(s):  
Diego Gabriel Mosteiro-Miguéns ◽  
Daniel De Bernardo Roca ◽  
Eva María Domínguez-Martís ◽  
Natalia Vieito-Pérez ◽  
Pilar Álvarez-Padín ◽  
...  
Keyword(s):  
Social Interactions ◽  
Cross Sectional Study ◽  
Public Healthcare ◽  
Healthcare Staff ◽  
Cross Sectional ◽  
Protective Measures ◽  
Protection Measures ◽  
Effective Measure ◽  
Awareness Campaigns ◽  
Cross Sectional Design

Vaccination against SARS-CoV-2 is postulated as the most effective measure to control the COVID-19 pandemic. However, the use of other protection measures is necessary to efficiently combat the spread of the virus. The aim of the present study was to determine the attitudes and intentions toward COVID-19 vaccination among non-regular social media users in Spain and to analyze how these factors could condition the acceptance of other personal protective measures once an individual has received the COVID-19 vaccine. A cross-sectional design was used in this work. In total, 719 subjects, ≥18 years old and of both sexes, were recruited from primary public healthcare centers to self-complete a questionnaire between March and April 2021. The majority of participants had a positive attitude toward vaccination and showed high levels of intention to be vaccinated. Likewise, except those participants who considered the vaccine to be the most effective measure to fight the COVID-19 pandemic, the rest of the participants highlighted the importance of continuing to limit social interactions and/or wearing masks even after being vaccinated. Since vaccination can create a perception of total immunity against SARS-CoV-2, it is necessary that healthcare staff organize effective awareness campaigns on the importance of maintaining personal protective measures until vaccination coverage is greater.

scholarly journals Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0246546
Author(s):  
Charles Kiyaga ◽  
Vijay Narayan ◽  
Ian McConnell ◽  
Peter Elyanu ◽  
Linda Nabitaka Kisaakye ◽  
...  
Keyword(s):  
Health Worker ◽  
Health Workers ◽  
Clinical Care ◽  
Implementation Fidelity ◽  
Facility Management ◽  
Health Facilities ◽  
Qualitative Assessment ◽  
Study Cohort ◽  
Cross Sectional ◽  
Hiv Exposed

Introduction A review of Uganda’s HIV Early Infant Diagnosis (EID) program in 2010 revealed poor retention outcomes for HIV-exposed infants (HEI) after testing. The review informed development of the ‘EID Systems Strengthening’ model: a set of integrated initiatives at health facilities to improve testing, retention, and clinical care of HIV-exposed and infected infants. The program model was piloted at several facilities and later scaled countrywide. This mixed-methods study evaluates the program’s impact and assesses its implementation. Methods We conducted a retrospective cohort study at 12 health facilities in Uganda, comprising all HEI tested by DNA PCR from June 2011 to May 2014 (n = 707). Cohort data were collected manually at the health facilities and analyzed. To assess impact, retention outcomes were statistically compared to the baseline study’s cohort outcomes. We conducted a cross-sectional qualitative assessment of program implementation through 1) structured clinic observation and 2) key informant interviews with health workers, district officials, NGO technical managers, and EID trainers (n = 51). Results The evaluation cohort comprised 707 HEI (67 HIV+). The baseline study cohort contained 1268 HEI (244 HIV+). Among infants testing HIV+, retention in care at an ART clinic increased from 23% (57/244) to 66% (44/67) (p < .0001). Initiation of HIV+ infants on ART increased from 36% (27/75) to 92% (46/50) (p < .0001). HEI receiving 1st PCR results increased from 57% (718/1268) to 73% (518/707) (p < .0001). Among breastfeeding HEI with negative 1st PCR, 55% (192/352) received a confirmatory PCR test, a substantial increase from baseline period. Testing coverage improved significantly: HIV+ pregnant women who brought their infants for testing after birth increased from 18% (67/367) to 52% (175/334) (p < .0001). HEI were tested younger: mean age at DBS test decreased from 6.96 to 4.21 months (p < .0001). Clinical care for HEI was provided more consistently. Implementation fidelity was strong for most program components. The strongest contributory interventions were establishment of ‘EID Care Points’, integration of clinical care, longitudinal patient tracking, and regular health worker mentorship. Gaps included limited follow up of lost infants, inconsistent buy-in/ownership of health facility management, and challenges sustaining health worker motivation. Discussion Uganda’s ‘EID Systems Strengthening’ model has produced significant gains in testing and retention of HEI and HIV+ infants, yet the country still faces major challenges. The 3 core concepts of Uganda’s model are applicable to any country: establish a central service point for HEI, equip it to provide high-quality care and tracking, and develop systems to link HEI to the service point. Uganda’s experience has shown the importance of intensively targeting systemic bottlenecks to HEI retention at facility level, a necessary complement to deploying rapidly scalable technologies and other higher-level initiatives.

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